Membership Application

Membership Application

This application is for individuals interested in participating in California Clubhouse programming.
California Clubhouse offers membership to individuals 18 years and older with a mental health diagnosis. We currently offer a Hybrid Program, in-person and virtual services. We require an application, eligibility form and an orientation to participate.

Eligibility form can be found by clicking here - Eligibility Form

All participation is voluntary and at no cost to members.
Name:*

First NameLast Name
Date Of Birth:*

MonthDayYear
Date
Pronouns:
(e.g. he/his, she/her, they/their etc...)
Preferred Language
Address:

Street Address

Street Address Line 2

CityState

Zip CodeCountry
E-mail:
example@example.com
Phone Number:
How can we best contact you?

Primary Care Provider
The following can be contact information for your case manager, therapist, primary care provider.

All information will be kept confidential.
Agency:
Care Provider Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Emergency Contact Information

We gather this information in case of any emergency. All information will be kept confidential.
Primary Contact Person

First NameLast Name
Relationship
Your emergency contact's relation to you
Phone Number
Please enter a valid phone number.
Email
example@example.com

Membership Information:
To be eligible for California Clubhouse programs, members need to live in San Mateo County*, be 18 years of age or older, and have a diagnosis of Schizophrenia Disorder, Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, Anxiety Disorder, PTSD or Depression.

All information will be kept confidential.

*If you do not reside in San Mateo County, connect with us via email or phone.
Mental Health Diagnosis*

Schizophrenia DisorderSchizoaffective DisorderBipolar DisorderMajor Depressive DisorderAnxiety DisorderPTSDOther
Please confirm your age and county:*

I am 18 years or olderI reside in San Mateo County
Medical History
Please provide medical conditions that you have (ex. high blood pressure, diabetes, asthma, Crohn's disease, etc.)
Allergies and Dietary Restrictions:
California Clubhouse strives to provide lunch to all members daily. However, if you have any allergies to certain foods or special dietary preferences, you are welcome to bring your own lunch.
Signature*

Clear
Signature Date:

MonthDayYear
Date
For more information about our program, feel free to visit our link tree page by clicking here - @californiaclubhouse
Should be Empty:

Emergency Contact Information